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INTEGRATING COMPLEMENTARY AND ALTERNATIVE MEDICINE INTO THE CURRICULUM
By: Gary Behrman
Presented at:
NACSW Convention 2012 October, 2012 St. Louis, MO
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Integrating Complementary and Alternative Medicine into the Curriculum
Complementary and alternative medicine (CAM) approaches, referred to as integrative health services (IHS), are used by a cross section of populations that intersect socioeconomic status, gender, race, religion and age. These approaches to health care include a variety of methods and approaches to relieve chronic and acute disabling conditions. HIS approaches to health care are gaining popularity and credibility both within and outside of the academy. According to Gant, Benn, Gioia, Seabury (2009), it is time for social work educators to integrate IHS into the curriculum along with traditional behavioral and cognitive approaches to social work practice. Rationales and pedagogical models for integrating IHS into the curriculum are offered, linking these with social work professional ethics and core competencies.
Key Words: Complementary and alternative medicine (CAM) Integrative Health Services (IHS) Social Work Curriculum Core Competencies Educational Policies and Accreditation Standards (EPAS) NASW Code of Ethics
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BACKGROUND
Social workers continue to provide the bulk of mental health services in the U.S.
(Block, 2006). A significant number of persons seeking services expect their health care
providers to be aware and knowledgeable about alternatives and complements to western
medical approaches for symptom relief and healing when their health is disrupted and/or
compromised (Gehlert & Browne, 2006). An ever increasing number of people are
seeking complementary and alternative medicine (CAM), here to forth referred to as
integrated health care (IHC) to address health/mental health issues (National Center for
Complementary and Alternative Medicine (NCCAM), 2012; Shapiro, Cook, Davydow,
Ottaviani, Leuchter, & Abrams, 2007; McCaffrey, Eisenberg, Legedza, Davis, & Phillips
2004). IHC is the common acronym being used in health and mental health care services
in western societies (NCCAM, 2012). Not only are people receptive to IHC, they are also
requesting their health care providers to explore diverse approaches that go beyond
medications and psychotherapy to address their overall health concerns (Kliger, 2000;
Mann, Gaylord, & Norton, 2001). The medical community is responding with innovative
approaches to integrating IHC with traditional health/mental health care (Faas, 2001).
IHC is requested by consumers and many will expect their social worker to have some
level of knowledge about various forms of IHC (Tindel, Phillips & Eisenberg (2005).
A generally accepted description of IHC/CAM among a wide range of social
scientists is that “CAM is a broad domain of resources that encompasses health systems,
modalities, and practices and their accompanying theories and beliefs, other than those
intrinsic to the dominant health system of a particular society or culture in a given
historical period” (Gant, et. al., 2009, p. 407). It is important to acknowledge that some
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social workers and/or clients may not consider various types of practices labeled as IHC
as alternative or complementary. They readily access these types of interventions before
seeking pharmacological and psychotherapies and consider these resources to be essential
components of their approaches to health/mental health care. Interventions and remedies
that some cultures and populations consider conventional, others view as alternative and
what some clients assess as successful outcomes, the medical community and/or social
workers may not concur.
With the rising costs of medications and the increasing lack of health insurance,
many adults are seeking alternatives for their health/mental health care (Ananth &
Martin, 2006). Factors, such as cultural norms, religious beliefs and familial distrust of
seeking help from “outsiders," creates skepticism for utilizing interventions that western
medicine takes for granted as legitimate and credible (Mann, Gaylord & Norton, 2004,
Wylie, 2004). The myriad of reasons why diverse populations seek IHC when addressing
their health care needs is being investigated (NCCAM, 2012; Coulter & Willis, 2007).
Also, the National Institute of Health (NIH) (2012), the Institute of Medicine (2005), and
the Center for Disease Control (CDC) (2005) are studying the efficacy and legitimacy of
IHC approaches to health and mental health care. Data from these research institutions
indicate that providing a variety of complementary/integrative and conventional
interventions are valuable and effective (NCCAM, 2012; D’Eramo, Papp & Rose, 2001;
Hill, Smith, Fearn, Rydberg & Oliphant, 2007).
GLOBAL RECOGNITION OF THE VALUE OF IHC
According to the World Health Organization (WHO) an IHC approach is needed
for effective and efficient health/ mental health delivery systems (WHO, 2008). They
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define IHC “as the organization and management of health services so that people get the
care they need, when they need it, in ways that are user-friendly, achieve the desired
results and provide value for the money” (WHO, 2008, p. 1). The following benefits of
IHC are listed, which provide guidance for Social Work programs when approaching
IHC education from a holistic, integrated system of learning (WHO, 2008).
Integration is about practical questions on how to deliver services.
It is a continuum involving discussions about the organization of various tasks
which need to be performed in order to provide a population with quality health
care; this can look differently for different populations.
Not all services have to be integrated into one package, but rather to avoid
disjointed services and strive to link all health care into connected services that
can be navigated by consumers.
Changing the way health care is provided may require a mix of political,
technical, and administrative collaboration, with input from all stakeholders.
Integrating IHC into the social work curriculum involves revisiting the implicit
and explicit curricula for areas where it makes sense to incorporate IHC into current
educational practices and structures for a particular program and its environment.
In order to be perceived as credible, many clients will expect their social workers
to be aware of IHC approaches to health and mental health care. The multitude of
complementary approaches to maintaining health are vast and it is unrealistic for students
to be informed and knowledgeable about all of them, but it is expected that students will
be aware of the predominant practices and methods being used among the populations
they are serving. Just as important, social work students need to be instilled with a respect
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for clients’ authority in determining the best method to treat their illness or malady when
there are no indications of harm to self and/or others (NASW, Code of Ethics, 2008).
Knowing how to integrate empirically tested and validated medical interventions, along
with indigenous approaches preserved for generations, may well be the future of
health/mental health care in western industrial societies (Block, 2006).
CHALLENGES FOR INTEGRATING IHC INTO THE CURRICULUM
Many social work educators are aware of the rapidly expanding utilization of IHC
approaches for health/mental health care and that clients and patients are seeking an
integrated approach with traditional health care strategies (Gehlert & Browne, 2006). The
immediate and long term challenges for social work educators are how to equip and
prepare students with an integrated experience that infuses the profession’s signature
person in environment (PIE) framework (Hutchison, 2011) and professional values when
incorporating IHC in the curriculum (Grant, Benn, Giola & Seabury, 2009).
Simply offering an elective IHC course once a year may not be meeting the needs
of both social work students and the people they will serve (Grant, Benn, Giola &
Seabury, 2009). What would be more responsive to the demands of both consumers and
students is the development of core competencies as a protocol for measuring and
assessing the prerequisite knowledge, skills, and values needed for responsible social
work practice, as well as familiarizing students with studies that demonstrate the
effectiveness of IHC models of social work practice that are valid and reliable.
When reading the literature on IHC it becomes paramount that there is a need for
social work programs to collaborate with other professional disciplines to develop
curricula that is responsive to the marketplace (Gant, Benn, Gioia, Seabury (2009).
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Schools of Medicine, Nursing and Allied Health are legitimate and essential partners with
Social Work in both teaching the next wave of health/mental health care providers and
creating research teams that employ both PIE (Hutchison, 2011) and participatory action
research (PAR) principles (Stringer, 1999). Basic integrative approaches to educating
social work students with other health care professions about IHC considers empirical
data that support the rationale for including and integrating IHC education throughout the
curriculum. The overlaps between medical model approaches, with its emphases on
medications and behavioral therapies, and IHC approaches can inform and support each
other when studied and researched in a multidisciplinary environment (NCCAM, 2012).
Applying an integrative, multidisciplinary approach to educating social work
students, recognizes that the social worker and the client possess expertise in managing
their health care (Stringer, 1999). Knowledge is mutually respected and shared when
determining which interventions are best suited for a particular person and his/her
environmental factors. “While non-conventional models are not identical, they tend to
share common principles. A holistic view is inclusive and considers the healing needs
unique to each individual’s presenting problem, history, other medical conditions,
environment, preferences and lifestyle” (McBee, 2008, p. 9).
CONCEPTUAL ORGANIZING FRAME
The curricular guidelines and models for IHC (Mann, Gaylord, & Norton, 2004)
require a theoretical foundation based upon empirical research findings, as well as
anecdotal testimonies from people who can attest to both the efficacy and applicability of
various types of IHC. Both theory and outcome measures based upon empirical research
designs will drive the infusion of IHC into the social work curriculum (Gant, Benn, Giola
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& Seabury, 2009). Linking practice with theory is imperative for being effective when
serving individuals and communities (Turner, 1996). The theories we hold within our
professional disciplines deeply influences how we interpret data, explain behavior, and
design our interventions (Guba & Lincoln, 1986). In order to integrate IHC education
into the social work curriculum a theoretical premise needs to be established, which
informs practice and research. For social work education this approach is systems theory
(Robbins, Chatterjee, Canda, 1998) “Over the past two decades, systems theories have
become widely used in social work practice, and both systems theory and the ecosystems
perspective have been proposed as meta theories for social work practice” (p. 48).
Systems theory recognizes that all relationships are dynamic and take place within an
interconnecting environment and that the social worker is aware of multiple aspects of
the person and his/her environment and how each is influencing the other (Thyer, 2001).
RESEARCH METHODS AND INTERPRETING IHC DATA
Within professional health care, interpretations of the effectiveness of IHC vary
immensely (Mann, Gaylord , & Norton, 2004; Institute of Medicine, 2005; National
Center for CAM, 2012 ). Some researchers are challenging conventional empirical
methods of testing the effectiveness of IHC interventions and resources: “CAM is not
simply a new array of therapeutic tools that needs to be evaluated; it presents other ways
to think about disease and therapeutics, and consequently new ideas about how research
should be strategically developed” (Fonnebo et. al., 2007, p. 5). These researchers
suggest that looking at a therapeutic intervention without really understanding the
cultural context in which it is being practiced does not allow researchers to analyze data
outcomes at their fullest capacity and a more complex approach to research is needed.
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Other researchers point to the inadequacies of current research methodologies in
capturing the effects of IHC interventions (Block & Jonas, 2006; Boon et. al., 2006;
Coulter, 2006). Issues are raised when researchers are dependent upon participants
accurately reporting and fully disclosing both the type and quantity of IHC they are
utilizing. One of many challenges for social work educators who are engaging in IHC
research and are currently teaching IHC is how to present valid and reliable data when
integrating IHC into the core curriculum. (Jonas, Beckner & Coulter, 2006).
When researching measurable outcomes and the effects of IHC interventions with
particular individuals and populations it is critical to take into consideration this
person/population’s particular strengths that he/she identify within his/her cultural and
religious environments. Incorporating strength's perspective when gathering and
analyzing data, researchers must closely examine how participants are portrayed and
represented (Saleebey, 1997). This approach is aligned with participatory action research
methods (PAR) (Wolcott, 1994; Stringer, 1999), which recognizes participants as having
authority and expert knowledge in interpreting their experiences and that historically
marginalized populations often are misrepresented by dominant authorities in society
(Kemmis & McTaggart, 2000; Wolcott, 1994).
There is a healthy tension between professional interpretations of the effects of
IHC and the ambiguities that exist among the multiple interpretations from the people
who utilize IHC. Multiple perspectives need to be considered when assessing the
credibility of health care outcomes. Both the practitioner and the client have something
valuable to contribute to the science and art of introducing IHC to assessment and
treatment plans (Stringer, 2007). This PAR approach to research and practice when
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applied to IHC education, includes the voices of both clients who self-report benefits
from utilizing IHC along with IHC practitioners who are practicing IHC in the field.
INITIAL PHASE OF INTEGRATING IHC ACROSS THE CURRICULUM
The starting point for integrating IHC into the curriculum is employing systems
theory and PIE (Hutchison, 2011), along with PAR (Stringer, 2009) frameworks to both
teaching and researching IHC. The complexities of persons interacting with their
environments, and vast array of non-traditional approaches to health and mental health
care being accessed by diverse individuals and populations are significantly influenced
by the cultural environment in which students will be practicing. Recognizing the
expertise and authority of the client(s) are essential components when approaching IHC.
NCCAM (2012) research is assisting social workers in gaining a richer, fuller
understanding of ways in which adults maintain health and the reasons they select various
alternatives for their health care. Social work educators will need to be aware and
sensitive to these emerging trends in IHC practice and research that are significantly
informed by cultural contexts. (Richardson & Barusch, 2006).
Linking IHC content across the curriculum, utilizing the core competencies
established by the Council on Social Work Education (CSWE) (2008), can assist in
organizing and conceptualizing this dynamic process of integrating IHC into the social
work curriculum. “The need to reframe EPAS [Educational Policy & Accreditation
Standards] to a focus on student outcomes based in practice behaviors, that is, what a
student must learn and be able to do, lead to a competency-based education approach.
Competency-based education is an outcome performance approach to curriculum design”
(CSWE, Advanced Gero- Social Work Education, 2010, p. 1).
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A precedent for this process is the collaboration between the Hartford-funded
CSWE Gero-Ed Center and the Association for Gerontology Education in Social Work,
(CSWE, Advanced Gero Social Work Practice, 2010). Another model for this process is
the Advanced Social Work Practice in the Prevention of Substance Use Disorders
(CSWE, 2008) and the most recent collaboration is the Advanced Social Work Practice in
Trauma (CSWE, 2012). All are models “for social work programs to use in the
development of concentrations specific to an area for the 2008 EPAS” (CSWE,
Advanced Gero Social Work Practice, 2010, p. 2). Just as competencies regarding
treatment for older adults, substance abuse, and trauma have been developed by CSWE,
there appears to be a clear mandate for integrating IHC approaches to social work
practice within the curriculum (Gant, et. al., 2009).
Using competencies outlined in EPAS as the standard for integrating IHC into the
social work curriculum will require guidelines that are flexible enough to adapt to meet
the regional and cultural needs that are specific to social work programs, their students
and constituents. Each IHC competency that could be used to integrate IHC across the
social work curriculum is presented in the appendix and the authors offer this framework
as a platform that could begin the process of dialogue within CSWE and among Schools
and Departments of Social Work of the need for integrated health/mental health care
material to be included in the curriculum for competency based social work practice
MODELS FOR INCORPORATING IHC ACROSS THE CURRICULUM
When teaching best practices in IHC education, innovative and well-tested forms
of interventions are needed that take into consideration a holistic perspective of the
person (Cook, Becvar, & Pontious, 2000). These best practices recognize that multiple
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environmental variables operate in a person’s life that contributes to his/her overall health
(Koenig, McCullough & Larson, 2000; Strozier & Carpenter, 2008). This holistic
approach to health/mental health care is an approach that incorporates the bio-psycho-
social-spiritual dimensions of a person and/or a population, increasing the possibilities for
achieving desired outcomes (Gant, et. al., 2009; Mann, Gaylord, & Norton, 2004). “An
approach that focuses on subjective and interpretative dimensions of clients ensures that
social workers will respect individual differences among people and avoid inappropriate
interventions.” (Richaradson & Barusch, 2006, p. 52).
Teaching IHC interventions generally begins with knowledge of the
environmental context (implicit curriculum) that both the program is situated and the
students will be practicing. The goal is to support best practices for particular populations
and/or individuals. Achieving a grasp of the practice wisdom that is gained from utilizing
IHC interventions and listening to consumers are essential when approaching social
work education from an implicit curriculum design The hallmarks of the social work
profession are noting the environment in which the student is learning and will be
practicing, respecting cultural and religious diversity, viewing a client’s presenting
problem from a systems theory, and designing interventions from a client’s strengths
perspective (Hutchison, 2011). This implicit curriculum approach is aligned with IHC
best practices and is supported in the IHC literature (NCCAM), 2012).
What is considered adequate knowledge, skills and values when teaching social
work students best practices that may involve religious rituals, eastern meditation
techniques, herbal remedies, and more? How will “adequate” be measured is a precursor
question that each faculty will have to discuss, debate and decide (Lenaway, Sotnikov,
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Corso, Millington, Halverson, Tilson, 2006). Much will depend upon the diverse cultural,
religious and socio-economic environments in which the social work program is located.
Taking into consideration the implicit curriculum, one of the social work educators’ goals
is to create a climate that promotes professional responsibility for students to be
informed, educated and unbiased when making referrals and/or providing IHC
approaches in the field. How much theoretical knowledge and practice skills are needed
and/or desirable for social work students, in the bachelor and/or masters level, during
their education and formation as professionals are important and necessary questions for
each program to be asking. The implicit curriculum is just as important to consider as the
explicit curriculum when creating models for integration (CSWE, EPAS, 2008)
The following models (Mann, Gaylord, & Norton, 2004) are useful when framing
the core curriculum around the ten core competencies of social work education (CSWE,
EPAS, 2008). These models are adopted and built upon schools of medicine approaches
to provide utilitarian guidelines for other disciplines, which enable diverse programs to
organize their pedagogical models around a series of assumptions about what might be
most effective and efficient for their individual programs when integrating IHC into the
curriculum. The appendix provides examples of defining, observing, and measuring
practice behaviors attached to each of the ten core competencies (See appendix).
MODEL1. KNOWLEDGE
When using Model 1, faculty focuses upon instilling knowledge about the basic
facts and assumptions about prevalent forms of IHC pertinent to the environment of the
social work program. This includes the scope and limitations of practicing IHC and
known benefits and potential negative interactions of IHC with traditional western
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medicine and behavioral sciences. The benefits of this model are that students are
introduced to basic terminology and achieve an understanding of various types of IHC
being widely utilized, along with an ability to make informed decisions about IHC
approaches to health care (Mann, Gaylord, & Norton, 2004).
This approach can be used in a stand-alone course, offered as an elective and team
taught by faculty and IHC practitioners in the community. It could also be offered as an
interdisciplinary course, with faculty from schools of medicine, nursing, allied health,
and social work. Another approach would be to create course modules in Human
Behavior & the Environment and/or individual/family practice courses. Research
methods could use examples taken from IHC studies and policy courses could examine
and critically analyze local, state, and national policies that impact IHC health/mental
health care delivery and insurance reimbursement plans.
Limitations are that basic IHC knowledge does not mean that students are now
competent to practice IHC, nor can they profess to be an expert in certain areas of IHC.
Caution is always needed when using this model so that students are not given the
impression that they are qualified to practice IHC. Although credentialing in many IHC
practices are not available, students should obtain IHC knowledge from reliable sources
supported in the literature and in the local professional community
MODEL2. NETWORKING & REFERING
This model builds upon the previous knowledge model and teaches students to be
competent in making referrals to IHC providers and be able to assess outcomes related to
IHC interventions (Mann, Gaylord, & Norton, 2004). This model implies that students
are aware of IHC providers and their practices in the community. Students are able to
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assess the credibility and efficacy of these practices, which entails interacting with IHC
providers and maintaining responsible communication with all referrals. While observing
IHC practitioners, students should be able to apply empirically based research methods
regarding patient outcomes.
This model could also be introduced into Research Methods courses, with
students using empirical methods to examine what works in IHC approaches and why.
Qualitative studies can be set up with students interviewing social workers and clients
regarding the use of IHC interventions. Teaching critical thinking skills is essential if
IHC is to be introduced into the curriculum in order to establish competencies in the area
of IHC practice (CSWE, EPAS, 2008).
The benefits of this networking approach to IHC education is that students will
learn how to respect client autonomy and self-determination and be able to ethically and
competently assess the value and limitations of utilizing IHC approaches to health/
mental health care. Aspects of this model are increased responsibilities regarding client
outcomes and the loss of control of the interventions being used with the consumer. It is
important that students learn what are the scope and limitations of their professional
responsibilities when making an IHC referral (Mann, Gaylord, & Norton, 2004).
III. APPLICATION
With this model, specific training is provided in IHC interventions. Students are
trained to practice selected IHC interventions from skilled IHC practitioners in the
community and/or faculty. This can take place in practice courses, where IHC techniques
and skills are modeled and demonstrated; seeking to instill levels of competencies based
upon course and program objectives. Also, students can be guided and mentored in field
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practicum, selecting program approved sites where certain skill levels can be achieved by
the student under the direction of the field supervisor and field coordinator.
Other options include an emphasis in the undergraduate social work program,
with students taking electives in IHC, both in the social work and other campus degree
programs. Graduate programs can establish concentrations and/or specializations in IHC
practice, with faculty comprised of multiple disciplines from various allied health/mental
health departments and recognized experts in the community practicing IHC.
The advantages of this model are that students are trained under the supervision of
competent and qualified IHC practitioners and monitored by faculty. The limitations are
that this model requires levels of accountability, and perhaps liability, for faculty and
students that schools may be reluctant to assume. Since there is limited credentialing for
many IHC interventions, making this determination that a student is competent to
practice IHC interventions can be quite nebulous (Mann, Gaylord, & Norton, 2004).
IV. INTERDISCIPLINARY
The need for collaboration among multiple disciplines becomes apparent when
social work programs begin to seriously address the issue of IHC education (Gant, et. al.,
2009; MacKenzie & Rakel, 2006). There are anecdotal criteria being generated by
physicians, social workers, chiropractors and other therapists that point to the benefits of
professional networking and resource enhancement when maintaining health/mental
health with adults (Barnes et. al., 2004; Frazer, Christensen & Griffiths, 2005; Hill et. al.,
2007). For example, recent research supports this holistic approach in the treatment for
depression in older adults. A meta-analysis of depression in older adults concluded that
there is evidence that mixing various types of medical/pharmacological interventions,
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with physical exercise, such as yoga, can improve mood and depression in older adults
(Frazer et al., 2005; NCCAM, 2012). In an integrative review of the literature, Lindberg
(2005) suggests that “meditation is beneficial for reducing acute anxiety and diminishing
despair among the elderly” (p. 375).
An example of creative interdisciplinary collaboration is the research being
funded by the Samueli Institute of Health (2008). Preliminary data are convincing and
thus some physicians are utilizing the complementary use of yoga for the treatment of
PTSD symptoms in enlisted military personnel at Veteran Administration sites. Other
research studies integrating yoga with pharmacological approaches are being conducted
with people experiencing chronic pain, depression and asthma and findings show a relief
of symptoms (Shapiro, et al., 2007; Steffensen, 2007; Waede et. al., 2004). Meta-analytic
studies indicate that the frequency and quality of physical activity lowers depression
levels in older adults (William & Strean, 2006). The overlaps between the medical model
with its emphases on medications/behavioral therapies and IHC approaches can inform
and support each other when studied and researched in a multidisciplinary environment.
“A holistic view is inclusive and considers healing needs unique to each individual’s
presenting problem, history, other medical conditions, environment, preferences and
lifestyle” (McBee, 2008, p. 9).
Establishing field sites where IHC approaches are being utilized by licensed
social workers in collaboration with other health/mental health care providers is
responsive to the needs of some students. Many social workers collaborate with other
professionals, thus creating field opportunities for students to have this multi-disciplinary
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knowledge and experience. This is a culmination of the process of integrating IHC
education into the social work curriculum.
Social work researchers have an opportunity to be initiating these types of studies
and be in the forefront of establishing empirical research that will inform best practices
for health care in the 21st century. Social work’s unique theoretical perspective can
contribute immensely to empowering populations whose approaches to healing are
marginalized by western medicine.
CONCLUSION
The curriculum challenge for social work faculty is to provide knowledge, skills,
and values to support specific populations and their unique health/mental health care
needs that students will serve. Some professional disciplines are both discussing and
implementing into their curricula a systematic approach that incorporates best IHC
practices (Elder, et. al., 2004; Mann, Gaylord, & Norton, 2004; Kligler, et. al., 2004;
Wetzel, Kaptchuk, Haramati & Eisenberg, 2003) One example of this is the Society of
Teachers of Family Medicine (STFM), (STFM, 2012). They are designing curricula that
address the changing educational needs of family physicians, which entail IHC education.
Like family physicians, social workers are bombarded in their clinics, agencies,
schools and hospitals with information and treatment requests from clients regarding IHC
strategies, such as, healing their depression, lowering their stress, and managing their
arthritis and blood pressure, through methods other than medication. Now is the time to
approach this challenge through competency education. An IHS approach to educating
students about health/mental health care has been successfully demonstrated with both
18
aging populations, substance abuse and trauma treatments (Emerson & Hopper, 2011;
Lee, Ng, Leung & Chan, 2009; McBee, 2008; Shafer, 2007; Wang, 2009).
For several decades, the social work profession has been encouraging educators to
include therapeutic approaches to healing that go beyond the medical model. (Derezotes,
2004). As western societies integrate more IHS approaches into health care, it is critical
for social workers and other health/mental health care providers to examine the benefits
and the risks involved in IHC interventions. Rising costs for acute health care and the
burgeoning older population will increasingly tax current health/mental health care
delivery systems. Shortages of resources and increasing populations without health
insurance will stretch our paradigms to be creative and cost effective when providing
services. Incorporating empirical research data about IHC and providing basic knowledge
and skills in generalist social work training are the wave of the future. Students will be
expecting this within their curricula and social work programs have the responsibility to
include an integrated approach to health/mental health care education in the 21st century.
APPENDIX
Advanced IHC Social Work Practice (Educational Policy and Accreditation Standards (EPAS), CSWE, 2008)
EPAS 2.1.1. Identify as a professional social worker and conduct oneself accordingly.
Measuring practice behaviors would involve creating rubrics that assess student
competencies in practicing across cultural, religious, gender and age orientations. Upon
graduation students will be able to “explore, identify, and resolve their own biases,
myths, and stereotypes” (CSWE, Advanced Gero Social Work Practice, 2010, p. 2) about
IHC approaches to health care. “Through self-reflection, students continue to assess their
19
IHC knowledge and practice behaviors and address their biases against and for IHC,
building knowledge to dispel myths regarding IHC.
Advanced practice would prepare Master in Social Work (MSW) students to play
key roles in interdisciplinary teams to assess and plan for clients’ care, respecting the
contributions of each discipline. MSW graduates will be able to “understand the
perspective and values of social work in relation to working effectively with other
disciplines in interdisciplinary practice” (CSWE, Advanced Gero Social Work Practice,
2010, p.8), which may consist of physicians, chiropractors, herbalists, yoga instructors, to
name just a few. The goal is to “understand the perspective and values of social work in
relation to working effectively with other disciplines” (CSWE, Advanced Gero Social
Work Practice, 2010, p. 9).
EPAS 2.1.2—Apply social work ethical principles to guide professional practice.
Under this standard, the curriculum would provide opportunities for students to
“recognize and manage personal values in a way that allows professional values to guide
practice and make ethical decisions by applying standards of the National Association of
Social Workers (NASW) Code of Ethics and, as applicable, of the International
Federation of Social Workers/International Association of Schools of Social Work Ethics
in Social Work, Statement of Principles” (CSWE, Advanced Gero Social Work Practice,
2010, p. 9) . With IHC integrated into research, policy and practice courses, social work
students will be able to recognize ethical conflicts, boundaries, and the issues related to
IHC practice and resolve them according to the NASW Code of Ethics (CSWE, 2011).
Many ethical issues will surface for social workers as they engage clients’ beliefs
and practices about IHC and surface what types of IHC the client may already be
20
engaged in or is seeking to engage. Social workers need to be “knowledgeable about the
value base of the profession, its ethical standards, and relevant law” (CSWE, Advanced
Gero Social Work Practice, 2010, p. 9). Based upon the profession’s values, special
attention is given to those who have limited resources and rely upon family, religious and
community resources to meet their health needs. Sometimes IHC may be the most
economical and simultaneously most efficacious for some clients. By educating students
through an integrative curriculum, social workers will be able challenge stereotypes of
persons who engage in IHC and advocate for their clients who choose to access IHC
based upon sound empirical data and anecdotal wisdom of their clients.
EPAS2.1.3. Apply critical thinking to inform and communicate professional
judgments
It will be critical for social work students to be able to distinguish, appraise, and
integrate multiple sources of knowledge, including research-based knowledge and
practice wisdom about IHC, and be able to analyze models of assessment, prevention,
intervention, and evaluation of IHC (CSWE, Advanced Gero Social Work Practice,
2010), In designing a curriculum that respects the data associated with IHC and those
who practice IHC, social work students upon graduation will be familiar with existing
data to inform their role with clients and their families, and professionals who practice
IHC. It is critical that social workers can communicate valid and reliable data about IHC
to clients, their families, professional colleagues, and community stakeholders. (CSWE,
Advanced Gero Social Work Practice, 2010; Runfola, Levine, & Sherman, 2006).
EPAS 2.1.4—Engage diversity and difference in practice
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It will be important that social work students be able to recognize the extent to
which a dominant culture’s values may oppress, marginalize, and alienate populations
who believe in and utilize IHC practices (CSWE, Advanced Gero-Social Work Practice,
2010). Recognizing only western medicine approaches to health care can create or
enhance privilege and power or not allow people access to “best” care (NCCAM], 2008).
Social workers are able to understand and dispel personal biases and perspectives
while supporting clients who choose IHC as a path to healing. “Social workers gain skill
in identifying and respectfully addressing varying values, beliefs, and behavior” (CSWE,
Advanced Gero Social Work Practice, 2010. p. 10). Research data indicate that social
workers will frequently encounter consumers who are marginalized as a result of
engaging in IHC approaches to their health (Graham et al., 2005; Kelly, Kaufman,
Kelley, Rosenberg & Mitchell, 2006; Mackenzie, Taylor, Bloom, Hufford, & Johnson,
2003). Thus having valid knowledge about IHC is vital in meeting this competency.
A significant number of social workers report using IHC in their practices with
marginalized populations (Henderson, L, 2000). By establishing standards for best
practices, the social work profession can lower the risk of causing unintentional harm to
marginalized populations and lower the stigma that can be associated with the use of
some types of IHC. Relying upon empirical research can dispel some of these biases and
oppressions even though some students and educators will have biases associated with
various types of IHC approaches to health care. These are contingent upon the social
worker’s religion, age, gender, socio-economic status (SES) and other influences. It is
critical that these biases are discussed in light of empirical research and reflected upon in
their cultural contexts so that students have sufficient self- awareness to discern between
22
biases and facts associated with IHC. The value of self-awareness as an outcome of
students’ gaining knowledge about IHC is researched by Elder and colleagues (2004).
EPAS 2.1.5—Advance human rights and social and economic justice
Whether counseling the Christian Scientist woman who refuses chemotherapy for
her cancer, supporting the Buddhist teenager who employs aroma therapy to address
school anxieties, or teaching yoga to war refugees to manage their post trauma
symptoms, it is critical that social workers are grounded in social justice standards
established by CSWE and the NASW Code of Ethics (NASW, 2008). A mandate in the
NASW Code of Ethics (2008) is for social workers to recognize and act upon covert and
overt forms of oppression towards populations who choose IHC approaches without
assistance from western medicine. This can be addressed throughout the curriculum if
standards are established, knowledge is made available, and skills are taught. Identifying
and surfacing the barriers that minority cultures and religions face when adopting IHC
can strengthen students to practice responsibly with sensitivity and competence. Students
will learn to respect and promote clients’ right to dignity and self-determination when
practicing IHC (CSWE, Advanced Gero Social Work Practice, 2010)
EPAS 2.1.6—Engage in research-informed practice and practice-informed research
Exploring the efficacy and safety of IHC interventions will be paramount in order
to claim that social workers are providing adequate and responsible care for those
entrusted to them (McBee, 2008). Reading the literature about IHC and creating research
protocols that study the efficacy of IHC are avenues that need to be pursued by social
work programs if the profession is to adequately address the future health care needs of
23
U.S. society (Gant, et. al., 2009; Barnes, Powell-Grinere, McFann, & Nahin, 2004;
Coulter, 2006; Ezzo, Bausell, Moerman, Berman, & Hadhazy (2001).
Emphasis within the social work curriculum is upon “evidence-based practice,”
which challenges practitioners to gather empirical data that indicate levels of
effectiveness in meeting clients’ health goals (CSWE, 2011). Simply proclaiming that an
intervention is effective because the social worker and the patient agree that it is will not
be sufficient evidence to randomly teach a particular IHC intervention. Multiple
confounding environmental, professional and personal factors should be taken into
consideration when teaching IHC based upon empirical research.
It is reasonable to begin with the premise that populations are flooding IHC
resources not only because it may be in vogue to practice yoga or receive acupuncture,
but people are utilizing these interventions because they are receiving desirable outcomes
(Institute of Medicine, 2005). Whether these outcomes are the result of the “placebo
effect,” vast numbers of people indicate that they seek both complementary and
alternative interventions that go beyond the scope of their physician’s and/or social
worker’s expertise, knowledge and skills (Coulter & Willis, 2007). “Practice-based
evidence” too convincing to be ignored or to be discredited as folklore or simply the
“placebo effect?” These questions demand attention within research courses if we are to
teach students evidence based best practices (Barkham & Mellor-Clark, 2003).
EPAS 2.1.7—Apply knowledge of human behavior and the social environment
Using systems theory to apply knowledge of IHC and using PIE as a model for
interpreting the systems in which a client is functioning, students will make the
connections between responsible use of IHC and social work practice. Identifying issues
24
of why, when, and how consumers choose to access IHC will enable the social worker to
practice from an informed professional stance when designing interventions (CSWE,
2010). Establishing CAM competencies will increase the possibility that social workers
who practice integrative health care and refer consumers to IHC will be doing so with
professional knowledge of how the environment shapes IHC practice.
EPAS 2.1.8—Engage in policy practice to advance social and economic well-being
and to deliver effective social work services
Will social work students have the knowledge, skills, and values to analyze,
formulate and advocate for policies that advance IHC practices that science and clients
value as credible? Assisting clients in obtaining insurance coverage for IHC
interventions is one of many policy advocacy roles that social workers might be called
upon to undertake. How do medical insurance policies inhibit IHC interventions that
empirical research has indicated are valid and effective? Teaching students how health
care policies impact consumers’ rights to IHC resources is a vital role for the social
worker who respects the autonomy and dignity of consumer choices (CSWE, Advanced
Gero Social Work Practice, 2010).
EPAS 2.1.9—Respond to contexts that shape practice
The pulse of health care services indicates that IHC is a billion dollar industry
annually. People are choosing IHC at higher rates than ever before (NCCAM, 2012).
Integrative models of Western and IHC approaches for health care are gaining
recognition and acceptance in the medical community (NIH, 2012). The social work
profession has a stake in this surgence of acceptance and trust in IHC approaches to
health care. How will social work educators influence and direct CAM practice, research
25
and policy development into the future? With the recent passage of new health care
legislation, The Patient Protection and Affordable Care Act (ACA) will trigger sweeping
changes in how health care services are delivered and by whom (Healthcare.gov, 2012).
Social work education is responding to these changes to meet the needs of individuals,
families, groups, communities and organizations by addressing service systems of care
(CSWE, 2012). The need for a concerted, organized and systemized approach to IHC
education, research and practice needs to be a priority (Gant, et. al., 2009).
EPAS 2.1.10(a-d)—Engage, assess, intervene, and evaluate with individuals, families,
groups, organizations, and communities
Each level of practice will require a set of competencies interwoven through the
curriculum. Many resources are available for this to occur (NCCAM, 2012, CSWE,
2012, CDC, 2005, NIH, 2012). Assessing intervening, and evaluating each requires a
skill set based upon reliable outcome measures. Integrating both theoretical and
empirical knowledge about IHC, along with cultural and religious wisdom practices,
schools of social work will determine which levels of practice are achievable and
desirable for their students. What is critical, is creating dynamic centers of learning,
which are preparing future and current social workers with the knowledge, skills and
values needed to be competent practitioners when accessing, intervening, and
evaluating IHC for the populations being served (CSWE, 2012; CSWE, 2010; CSWE,
2008). Tasks that remain are to organize and deliberate a cohesive and comprehensive
plan of IHC education that can draw upon the best practices among social work
programs , social work practitioners, that interface with other professional disciplines
26
currently engaged in integrating CAM into the curriculum (Gant, et. al., 2009; Elder,
et.al., 2007; Klinger, et. al., 2004).
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Gary Behrman, PhD, LCSW, M.Div. obtained his doctoral degree in Social Welfare from the University Albany in NY, his Master of Social Work from Saint Louis University and his Master of Divinity from St. Meinrad School of Theology. He is a licensed clinical social work and a Gero-Ed Center Expert Trainer with the Council Social Work Education. His research and publications focus on how and why people flourish following a crisis and the functions of religion and spirituality in this process. He is a frequent speaker at national and local conferences and currently teaches at Lindenwood University’s social work program in St. Charles, MO.
